Provider Demographics
NPI:1639317860
Name:GRANBERRY, MINDY L (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90997
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78709-0997
Mailing Address - Country:US
Mailing Address - Phone:512-261-3584
Mailing Address - Fax:512-524-3649
Practice Address - Street 1:20424 HAYSTACK CV
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-6441
Practice Address - Country:US
Practice Address - Phone:512-261-3584
Practice Address - Fax:512-524-3649
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist